Other strategies based on findings from surveillance (I)

The intention of surveillance in the community was not only to determine the level and patterns of antibiotic use, but also to identify inappropriate use in key facility types, symptom conditions, and among specific antibiotics, so that messages and interventional strategies could be focussed. These potential strategies are discussed below.

Development and dissemination of messages:

It was found from surveillance that fluoroquinolones, extended spectrum penicillins and cephalosporins were the most commonly used classes of antibiotics in the private sector and that they were often used for respiratory infections and diarrhoeas. The main message to the

community would be to not use these antibiotics for symptoms such as runny nose, common cold and simple diarrhoeas which are often caused by viruses. Messages given could vary according to prior knowledge and understanding of the audience but would include:

(i) There is high use of antibiotics in symptoms such as runny nose, sore throat, cough and cold and simple diarrhoea.

(ii) Antibiotics such as ciprofloxacin, amoxicillin and cephalexin are usually not indicated in these infections.

(iii) The more antibiotics we use, the more resistance will develop. Therefore if we use antibiotics inappropriately, we are unnecessarily causing resistance.

(iv) Resistance among bacteria means that the antibiotics will no longer work and we will have treatment failures, increased costs and complications.

(v) Using unnecessary antibiotics may lead to unnecessary adverse effects.

These messages could be disseminated through various means, such as posters, pamphlets or through mass media:

(i) Using Posters and Pamphlets: Posters could be prepared with these simple messages in local language and also in English. These could be put up in places like waiting areas of hospitals, private clinics and public facilities like bus stations, railway stations, and main shopping areas. Short messages could be exhibited on buses and auto rickshaws. Pamphlets could be given to doctors and pharmacists to be distributed to their patients.

(ii) Mass media: Newspapers, magazines, radio and television could be engaged to increase awareness. Help from journalists could be obtained to write articles related to antibiotic use and its consequences in local newspapers. Another dissemination strategy is to telecast sub-captions on antibiotics prior to popular programmes. Television chat shows could also be an option to discuss cases about antibiotic misuse and resistance.

For the above messages, it could be useful to apply approaches that are frequently used in other fields such as social sciences and even the pharmaceutical industry. These approaches could help in developing and disseminating messages on antibiotic use and resistance to the public and specific groups of stakeholders. In social sciences, the ‘Ps’ of social marketing, product, place, price and promotion have been used to change the behaviour of another ‘P’, people [177]. Some of the principles include behaviour change as a benchmark, audience research, segmentation of target audiences, creating appealing and motivational interactions, and using a marketing mix coupled with good communication. The principles of social marketing are increasingly being applied to promote public health and also in the area of antibiotic use.

An example of this is the inexpensive information campaign which targeted the communities in northern Italy. This along with a newsletter targeting healthcare providers significantly decreased total rates of antibiotic prescribing [178]. Buzz marketing is another approach which has been used in the area of antibiotic use and resistance [179]. This approach is commonly used in the pharmaceutical industry for promoting products, services and ideas. It works best for ideas that are memorable, where small changes in behaviour have big effects over time, and when patients perceive the benefit of the idea.

Interventional strategies:

Human behavior depends on time, place, person and many other factors. Culture, surroundings, circumstances, finance, the lack of basic necessities, social relations and stress may all affect beliefs about health and illness [180]. This in turn may affect health seeking behavior. Antibiotic use in humans is affected by behavior at all levels, from the initial decision of patients to seek a healthcare provider to the full completion of treatment. The behavior and factors affecting this can be at various levels. This includes individual (patient or healthcare provider), interpersonal (stakeholder interactions), facility (a number of healthcare levels including diagnosis and treatment), community (peer practices, beliefs, cultural issues) and policy (regulations and implementation). For strategies to be effective and sustainable it would be important to apply models or theories of behaviour change to the interventions that are to be developed [181]. There are various models that could be applied such as the educational model, stages of change theory, ‘precede/proceed’ model, social learning theory, and academic detailing, to name a few [181]. However, for optimal behavioural change in antibiotic use, one of the other models that could prove quite effective could be the ‘mainstreaming’ model. This has been used for gender mainstreaming with reasonable success [182]. To ensure that mainstreaming works, it should be a core part of planning. Various decisions of the society should be analyzed through the mainstreaming perspective and consequences that arise should be visible. Mainstreaming could be a game changer in modifying behavior at various levels of antibiotic use in the society.

It would be important to apply some of the principles espoused in these models and theories when developing the following interventional strategies:

(i) Targeted programmes: These programmes could target various groups such as youth, mothers, social clubs, non-governmental organization (NGO) workers, health aids and school students. A team consisting of doctors, pharmacists and a research team member could visit the target group and give simple messages. At schools, besides giving messages, children could carry out a set of activities such as street theatre, competitions and poster development in their own community.

(ii) Developing treatment algorithms for acute respiratory infections and diarrhoeas: Simple guidelines for management of acute respiratory infections and diarrhoeas could be developed by local GPs. They could make realistic protocols that can be followed and true to the clinical scenarios faced in everyday work. The research team can facilitate the process to ensure guidelines consistent with the main message and good practice. GPs should be encouraged to distribute this information freely among their peer group and get feedback about guidelines.

(iii) Self monitoring and peer review of prescribing for doctors: An anonymous set of exiting patient interview forms showing prescribing practices can be presented in turn by different GPs. Compliance with guidelines, appropriateness and difficulties could be discussed. The

research team could ensure that no individual’s prescribing practices could be identified by peers. Changes in behaviour could be assessed using a monitoring system for antibiotic use.

(iv) Self monitoring and peer review of dispensing for pharmacists: Pharmacists and local pharmacy shop owners could be asked to cooperate in a programme of simulated patient surveys whereby each month a random selection of pharmacy shops are visited and the pharmacist asked to sell a “strong medicine” for mild respiratory infection or diarrhoea. A standardised instrument could be developed. The research team should ensure anonymity. In this way, they will be able to discuss changing their own behaviour.

Implementation of such multipronged strategies involving all stakeholders is the need of the hour, and should be simultaneous, comprehensive and sustainable. The lives of people from various walks of life, spanning different age groups, and experiencing a variety of circumstances, are at stake due to antibiotic resistance [183].

Evaluating the impact of future interventions:

Change of prescribing or dispensing behaviour can be evaluated by surveillance of antibiotic use in respiratory infections and diarrhoeas. This can be done by measuring trends before, during, and after intervention with regard to: (i) percentage of patients receiving antibiotics;

(ii) percentage of patients receiving fluoroquinolones; (iii) percentage of patients receiving inappropriate antibiotics for respiratory infections and diarrhoeas; and (iv) percentage of resistance of E. coli to specific antibiotics, particularly fluoroquinolones.

Extra information on behaviour could be gained from: (i) Dispensing behaviour of shop owners through simulated patient surveys enabling assessment of OTC antibiotic use; (ii) Prescribing behaviour of doctors through regular prescription audit and peer review; and (iii) Process information indicating the extent and quality of implementation of interventions.